Book Review

Unnatural History: Breast Cancer and American Society

N Engl J Med 2008; 359:1635-1636October 9, 2008

Article

Unnatural History: Breast Cancer and American Society
By Robert A. Aronowitz. 366 pp., illustrated. New York, Cambridge University Press, 2007. $30. ISBN: 978-0-521-82249-7

There is a complex emotional, social, and cultural overlay to the experience and treatment of breast disease that makes breast cancer unique. Although physician and historian Robert Aronowitz drew from the writings of key patients, physicians, and cancer researchers over the past two centuries in composing this history, his principal aim is a critique of society in general and medicine in particular. His book is therefore not a natural history of breast disease but an Unnatural History, as the title proclaims. It is structured predominantly around three main topics: the radical mastectomy of the Halsted era at the turn of the 20th century, the “do not delay” campaign of the early 1900s, and the mammographic screening campaigns of the latter half of the 20th century.

William Halsted began with the hope and belief that extensive breast surgery would save lives. But through his careful clinical follow-up and record keeping he clearly documented the fact that his patients continued to die of cancer even after removal of the breast, chest-wall muscles, and axillary contents. Nevertheless, the patient's experience of death was radically changed by surgery. The first woman discussed in the book, Susan Dillwyn Emlen, died in 1819 after 6 years of struggling with a cancer that ulcerated through her skin and was obvious to her and to her family and friends. A century and a half later, Rachel Carson was able to hide her cancer from all but her closest confidants because of improved surgical techniques. After surgery, women rarely died of local disease but rather from distant metastases. Aronowitz writes that the end point of surgery for advanced cancers changed from increased survival to local control, but there was still value for patients in the procedure.

Illustration from the Surgical Papers of William Stewart Halsted, Volume 2, Plate 50.

Halsted and others noted that all cancers were detected by the patients themselves and that many women delayed seeking care. The physicians believed that if patients sought care earlier, their outcomes would be improved. This reasoning developed into the “do not delay” campaign of the early 1900s. Women were bombarded with advertising, public education films, and medical advice to perform breast self-examination and to report any lumps to their doctors. Aronowitz describes two unfortunate outcomes of this program: first, many women became overly fearful of cancer and of examining their own breasts, and second, guilt and blame for a poor outcome could be transferred to the patient for failing to detect a lump earlier. Recent clinical trials have concluded that breast self-examination does not reduce mortality but does increase the frequency of unnecessary biopsies. Some have questioned whether the results of such studies are conclusive. Ultimately, women and their physicians are left not knowing how to balance the costs of breast self-examination (potential increased anxiety and fear, increased visits to doctors, and greater likelihood of surgery for benign conditions) with the benefits — because the benefits, unlike the costs, remain unclear.

The third section of the book describes the advent of mammographic screening in the 1980s. Screening has unquestionably diminished the size of cancers at diagnosis and moved back the stage at which they are detected. The death rate from breast cancer started to decrease in 1990, and a portion of the decrease is attributable to screening. However, screening has also increased the number of women in whom clinically insignificant cancers are diagnosed (i.e., cancers that otherwise would not have been evident during their lifetimes), the number of breast surgeries for benign lesions, and the number of women with diagnoses of lesions of uncertain significance. Some believe that the anxiety and overtreatment associated with mammography may outweigh the benefit of earlier diagnosis.

This book is a thoughtful and thought-provoking plea to remember the collateral damage from the war on cancer. It is a call for physicians and scientists, as well as the general public, to critically examine every aspect of the diagnosis and treatment of breast cancer — not only the patient with breast cancer but also the majority of healthy women concerned about the possibility of receiving a diagnosis of breast cancer. Aronowitz does not offer an answer as to how we should accomplish this but opens the door for those willing to attend to the lessons of history to avoid repeating the mistakes of the past.

Susan C. Lester, M.D., Ph.D.
Brigham and Women's Hospital, Boston, MA 02115